Effects of simulated altitude (normobaric hypoxia) on cardiorespiratory parameters and circulating endothelial precursors in healthy subjects
- Michele M Ciulla1_596Email author,
- Michela Cortiana2_596,
- Ilaria Silvestris2_596,
- Emanuela Matteucci3_596,
- Elisa Ridolfi3_596,
- Fabrizio Giofrè1_596,
- Maddalena Zanardelli4_596,
- Roberta Paliotti1_596,
- Agostino Cortelezzi2_596,
- Alberto Pierini1_596,
- Fabio Magrini1_596 and
- Maria Alfonsina Desiderio3_596
© Ciulla et al. 2007
Received: 05 March 2007
Accepted: 08 August 2007
Published: 08 August 2007
Circulating Endothelial Precursors (PB-EPCs) are involved in the maintenance of the endothelial compartment being promptly mobilized after injuries of the vascular endothelium, but the effects of a brief normobaric hypoxia on PB-EPCs in healthy subjects are scarcely studied.
Clinical and molecular parameters were investigated in healthy subjects (n = 8) in basal conditions (T0) and after 1 h of normobaric hypoxia (T1), with Inspiratory Fraction of Oxygen set at 11.2% simulating 4850 mt of altitude. Blood samples were obtained at T0 and T1, as well as 7 days after hypoxia (T2).
In all studied subjects we observed a prompt and significant increase in PB-EPCs, with a return to basal value at T2. The induction of hypoxia was confirmed by Alveolar Oxygen Partial Pressure (PAO2) and Spot Oxygen Saturation decreases. Heart rate increased, but arterial pressure and respiratory response were unaffected. The change in PB-EPCs percent from T0 to T1 was inversely related to PAO2 at T1. Rapid (T1) increases in serum levels of hepatocyte growth factor and erythropoietin, as well as in cellular PB-EPCs-expression of Hypoxia Inducible Factor-1α were observed.
In conclusion, the endothelial compartment seems quite responsive to standardized brief hypoxia, possibly important for PB-EPCs activation and recruitment.
The identification in the peripheral blood (PB) of endothelial precursors (EPCs) derived from bone marrow (BM) and the demonstration of their prompt mobilization, incorporation, and differentiation to the sites of injury have suggested that EPCs could serve as endothelial reparative reserve of the damaged vascular endothelium [1–3]. In addition, in an experimental model of tissue injury it has been demonstrated that, even when injected peripherically, cells derived from BM are able to home to the site of damage  contributing to neovessel formation . Therefore, the frequency of PB-ECs has been proposed as diagnostic, therapeutic or prognostic marker of vascular injury and neovascularization [6–9]. Unfortunately, the majority of clinical studies on EPCs focuses on the role of these cells in cardiovascular diseases and no systematic studies exist regarding their variations in healthy subjects, for example under hypoxic conditions. Pathologic tissue ischemia in experimental animal models has been demonstrated to increase the frequency of EPCs, thereby contributing to neovascularization. Cytokines seem to be involved in the mobilization of BM-EPCs . Systemic administration of hepatocyte growth factor (HGF), a multifunctional cytokine involved in tissue repair, induces myocardial angiogenesis which contributes to the improvement in cardiac performance of mice after myocardial infarction . It is known that HGF may exert direct or indirect effects on endothelial cells, also through Vascular Endothelial Growth Factor (VEGF) production [12, 13]. The expression of Met, the specific receptor for HGF, is increased in the myocardial infarcted area, where it coexists with CD31, CD34 and WWF-positive cells . The possible role of HGF in activation and recruitment of EPCs in ischemic areas is still unknown. The chemokine SDF-1/CXCL12 and its receptor CXCR4 are critical mediators of the ischemic specific recruitment of circulating EPCs, a loop probably regulated by hypoxia via Hypoxia Inducible Factor-1 (HIF-1) transcription factor activation . HIF-1 is the heterodimeric (α/β) transcription factor that controls tissue oxygen homeostasis [15–17]. The involvement of HGF in the expression of the ligand/receptor couple CXCL12/CXCR4 has not been studied in EPCs, but we have demonstrated that HGF induces CXCR4 in carcinomas [18, 19].
Under physiological conditions, exercise is known to upregulate EPCs and to decrease the rate of EPCs apoptosis . Furthermore, in vitro induced-anoxia has been shown to enhance the differentiation of peripheral blood mononuclear cells from healthy subjects into EPCs . In a recent paper we have shown that high-altitude hypoxia and exercise oxygen demands are strong stimuli for clonogenic endothelial cell activation . At this regard, no studies are currently available in healthy subjects linking the PB-EPCs response with the hypoxia-specific regulation system. However, hypoxia during ascent to high altitude is responsible for an enhanced expression of Erythropoietin (Epo) and an augment of vascular tone closely related to the increased serum concentration of endothelin (ET)-1. Epo and ET-1 are known target genes of HIF-1 .
The present paper aims to assess the effect of a brief standardized normobaric hypoxia in healthy subjects on the frequency of PB-EPCs, and to evaluate early molecular events implicated in the activation and/or recruitment of these cells. To this purpose, we studied the involvement of HIF-1 transcription factor by measuring the expression of the inducible α-subunit and of HIF-1 target- genes. Based on the knowledge in pathological conditions, we chose genes involved in angiogenesis, such as HGF and ET-1, as well as in EPCs recruitment and in erythropoiesis such as CXCR4 and Epo.
We enrolled 8 caucasic male healthy non-smokers, non-obese, normo-cholesterol, normotensive, not currently under pharmacological treatment volunteers between our attendant students. No subject had a history of pulmonary disease or respiratory symptoms and all were native sea level dwellers, who had not been at altitude in the preceding three months. Most were not regular exercisers who took part in a range of activities, mainly football. As normal reference, PB-EPCs values obtained in a previous study were used . The study was approved by the Ethical Committee and the subjects signed a consent form.
Simulated altitude (normobaric hypoxia)
Subjects set quietly breathing room air for five minutes before breathing an oxygen mixture at 11.2% (corresponding to 4850 m) for 1 h by using an hypoxicator (GO2 Altitude, Biomedtech, Australia).
During the experiment the main cardiorespiratory parameters were measured. Recordings of Systolic and Diastolic Pressures (SBP, DBP) and heart rate (HR) were obtained non-invasively (Finapress, Ohmeda, Louisville-CO, USA); a gas analyzer (Cosmed Quark b2, Italy) and an oxygen saturimeter (Envitec, Wismar, G) were used to obtain the following parameters: Inspiratory Fraction of Oxygen (FiO2), Alveolar Oxygen Partial Pressure (PAO2), Spot Oxygen Saturation (SpO2), Respiratory Frequency (RF), Tidal Volume (Vt). All cardiorespiratory parameters were measured continuously except SBP and DBP, that were measured at 10 min time intervals.
Blood sampling and analysis of Endothelial Precursors
A 10 ml PB-sample was obtained from all subjects at each time studied: before (T0) and at the end of the experimental hypoxia (T1), and after 7 days (T2). The frequency of PB-EPCs, defined as KDR+/CD34+/CD45-, was obtained by Flow Cytometry (FACScan, Becton Dickinson, San Jose, CA) according to a previously described procedure on 100,000 events per sample .
Measurement of HGF, Epo and ET-1 levels in the serum
HGF was measured in human serum with Quantikine Immunoassay Kit (R&D System, Minneapolis, MN) following the manufacturer's instructions. Serum concentrations of soluble Epo and ET-1 were assessed by commercial enzyme-linked immunosorbent assays (R&D System). The normal reference values for Epo were within 3.3–16.6 mIU/ml. For ET-1 the sensitivity was 0.14 pg/ml. All the values were calculated using standard curves generated with specific standards, according to the manufacturer's recommendations .
Slides were prepared with EPC cells, obtained with immunobeads CD34+ separation, using a cyto-spin. For fluorescence microscopy, the cells were permeabilised with 0.2 % Triton × 100 and were incubated at room temperature with anti HIF-1α antibody (1:50, Transduction Laboratories, Lexington, KY) for 2 h. Non permeabilised-cells were incubated at room temperature with anti CXCR4 antibody (10 μg/ml, MAB172 R&D System) for 1.5 h. Green fluorescent Alexa Fluor-488 (1:800), used as secondary antibody, was let to react for 1 h in the dark. Nuclear staining was performed with DAPI (1:2000). The coverslips were mounted with Entellan (Merck, Darmstadt, Germany), and the cells were examined with a fluorescence microscope (Nikon Eclipse 80i with digital camera DS5MC) at room temperature in the dark. Images were collected through the specimens at 400 × magnification, using an objective Plan APO VC (N.A. 1.40). Analysis of the images was performed according to a previously described procedure .
Data obtained for cardiorespiratory parameters were analyzed using a computer statistical software (SPSS – Rel 6.1.1; SPSS Inc., Chicago, Ill). All the quantitative variables were tested for Gaussian distribution with the Kolmogorov-Smirnov test. Changes in any of the studied variables at each time intervals were tested by ANOVA. The relationship between PB-EPCs changes from T0 to T1 and other variables at T1 was tested by regression analysis. In all cases, p < 0.05 was considered significant.
Evaluation of clinical parameters in healthy subjects exposed to normobaric hypoxia
Effects of hypoxia on cardiorespiratory parameters and PB-EPCs
T0 vs T1 p
T1 vs T2 p
20.9 ± 0.5
11.8 ± 0.9
21.2 ± 0.5
- 43.2 ± 5.3
104.5 ± 14.9
30.2 ± 14.0
99.8 ± 15.8
- 71.8 ± 13.4
97.5 ± 1.4
86.8 ± 4.7
96.9 ± 05
- 10.9 ± 5.0
16.0 ± 2.9
14.4 ± 3.4
15.8 ± 3.0
- 8.3 ± 21.6
0.57 ± 0.09
0.56 ± 0.26
0.6 ± 0.2
- 2.2 ± 43.6
64.0 ± 8.8
77.4 ± 10.8
66.6 ± 10.3
+ 20.9 ± 4.3
124.7 ± 4.9
120.3 ± 8.6
122.0 ± 9.0
- 3.5 ± 4.7
71.1 ± 3.1
73.0 ± 5.6
76.3 ± 8.2
+ 2.7 ± 8.6
0.38 ± 0.56
0.65 ± 0.72
0.14 ± 0.20
+ 237.1 ± 264.5
In all subjects the cardiac response was characterized by a significant increase in HR (from 64.0 to 77.4 b/min; p < 0.0001) as well as by little reductions in SBP (5/8 subjects) and increases in DBP (5/8 subjects), that did not reach the statistical significance. The pulmonary response was limited, showing little decreases in RF (6/8 subjects) and in Vt (4/8 subjects) not statistically significant (Table 1).
Oxygen responsive molecules after normobaric hypoxia
The expression of HIF-1α and CXCR4 was assessed by immunofluorescence using PB-EPC, and representative results are shown (Figure 3B). At T1 the expression of HIF-1α protein was strongly enhanced, as shown by the increased fluorescent signal throughout the cell including the nucleus (see merge, c). Stainings with the secondary antibody alone were performed (negative controls), and we did not observe differences in the fluorescence between T0 and T1 (data not shown). Due to the scarce number of PB-EPC collected, it was impossible to perform a quantitative analysis of HIF-1α protein-levels by Western blot. We did not observe changes of CXCR4 protein expression at this early time after hypoxia exposure. After hypoxia a prompt and significant increase in the serum Epo levels was observed in 7/8 subjects included in the experiment, with a change from 7.07 ± 1.04 to 9.91 ± 2.26 mIU/ml (p = 0.009). This increase was directly correlated with the change in PB-EPCs from T0 to T1 (r = 0.65; p < 0.05). A concurrent increase in ET-1 serum levels was observed, that did not reach the statistical significance (from 0.18 ± 0.20 to 0.49 ± 0.58 pg/ml, p = 0.197) (Figure 3C, D).
It is well established that endothelial cells acquire several functional properties in response to diverse extracellular stimuli, and this expression of an altered phenotype is referred to as endothelial cell activation . While it is recognized that endothelial cell activation has a principal role in host defence, recent studies also demonstrate that endothelial cells are capable of complex molecular responses against various forms of stress including hypoxia. Hypoxic stimulus on endothelial cells causes transcriptional induction of genes encoding growth factors for blood vessels and remodelling enzymes . These events are associated with endothelial cell clonogenic activation resulting in loosing/acquiring specific surface markers.
In the present study we have shown that the endothelial compartment promptly reacted to acute hypoxia by increasing the CD34/KDR responsive elements, that are considered PB-EPC. Since KDR is the Fetal liver kinase-1 (Flk-1), i.e. the VEGF receptor, this switch might be functional to the establishment of VEGF-responsive cells . The activation of the PB-EPCs observed was probably related to the systemic release of Epo, and a direct correlation was found between the change in PB-EPCs from T0 to T1 and the serum levels of Epo. The PB-EPCs activation might be mediated by HIF-1α, that is known to regulate the expression of a wide variety of genes involved in neoangiogenesis under various pathophysiological conditions [15, 23].
At T1 in PB-EPCs, we observed an enhanced expression of HIF-1α protein, the hypoxia inducible-subunit of the heterodimeric transcription factor HIF-1. Thus, the endothelial compartment seemed to promptly react to a short hypoxia exposure in healthy subjects. Under normoxic conditions, HIF-1α is hydroxylated by prolyl hydroxylases. This reaction enables the von Hippel-Lindau (VHL) protein-binding and HIF-1α degradation by the proteasome. Under hypoxic conditions, prolyl hydroxylases are inactive, HIF-1α is stabilized and translocates to the nucleus as an heterodimer with the constitutive HIF-1β. This control mechanism, i.e. protein stabilization, might be responsible for the rapid enhancement in HIF-1α expression observed after normobaric hypoxia.
The HIF-1 complex binds to hypoxia-responsive elements (HRE) sequences in the promoters of target genes, causing activation of transcription. Under hypoxic conditions, HIF-1 is known to transactivate VEGF, Epo, and ET-1 as well as genes involved in cell recruitment such as the chemokine receptor CXCR4 and the ligand SDF-1/CXCL12 [14, 23, 29, 30]. In our study despite an absolute increase in serum ET-1, the changes observed were not significant. Also, CXCR4 expression at T1 in PB-EPCs was unaffected. The lack of significant changes in ET-1 and CXCR4 was probably related to the short exposure to hypoxia. In fact, molecular events controlled at transcriptional/translational level need longer times to occur. Consistently HGF, a growth factor involved in neoangionenesis like VEGF [12, 13], was found increased in the serum of healthy subjects exposed to normobaric hypoxia. HGF is known to be rapidly released in the blood after various types of tissue injuries. Present as a pro-form in tissue extarcellular matrix, HGF is activated and released by proteolytic mechanisms . Thus, HGF seemed to play a critical role in early stages of EPCs activation, and might contribute to the triggering of later molecular events.
Studies are in progress at examining these possible changes dependent on early HIF-1 alpha expression, regarding for example the transcription via HIF-1 of CXCR4 and Met receptors important for cell scattering and homing [11, 14]. Met expression possibly enhances the sensitivity to HGF. Also HIF-1 expression, regarding for example CXCR4 and Met receptors important for cell scattering and homing [11, 14]. Met expression possibly enhances the sensitivity to HGF. Also HIF-1 might regulate its transcription due to the presence of HREs in the promoter, amplifying therefore the response to hypoxia .
The hypoxic cardiorespiratory response is a complex interplay between several distinct mechanisms, and the O2 level-decrease is sensed by specialized chemoreceptor cells that regulate cardiovascular and ventilatory response . The normal hemodynamic response to acute hypoxia consists of an increase in HR and a modulation of the vascular tone, with vasodilatation of peripheral vessels and constriction of the vessels of the pulmonary vasculature to shunt blood away from the poorly ventilated region. In our subjects the increase in HR is prompt and prevalent (8/8 subjects), confirming that small reductions in PAO2 are detected by peripheral chemoreceptors eliciting the sympathetic chemoreflex . On the ventilatory side, the normal response consists of a gradual increase in ventilation that intensifies over the following hours and days . This ventilatory response was not univocally observed in our subjects probably because the hypoxic exposure was too short to recruit the carotid chemoreceptors .
The wide range of oxygen tensions found in healthy tissue makes it difficult to establish an universal value to define hypoxia . Based on the medical definition of high altitude, consisting in an elevation of 2700–5500 m above sea level , in our study we have set the FiO2 to an altitude of 4850 mt. On the endothelial point of view, the definition of hypoxia could be the level of oxygen at which the clonogenic PB-EPCs response starts. Furthermore, this cellular response might be used for studies aimed to predict the adverse effects of high altitude since it has been shown that limited informations can be obtained by assessing only cardiorespiratory physiological variables at sea level and at a range of simulated altitudes .
On the technical point of view, the main limitations of all studies based on circulating EPCs enumeration consist in the lack of a uniform immunophenotype definition of EPCs and therefore of an experimental method to discriminate between different populations . Furthermore we do not provide any informations on EPCs function such as migration or ability to form colonies; however at this regard we have previously shown that high-altitude hypoxia and exercise is able to switch on the endothelial colony-forming unit capacity .
In conclusion, the cellular and molecular data indicate an evident excess in the response of the endothelial compartment when considering a physiological stimulation. In healthy subjects the frequency of PB-EPCs may be considered as a marker of endothelial activation after exposure to physiological normobaric hypoxia, corresponding to an altitude of 4850 mt, that may be important for neovascularization. This study may contribute to a better understanding of the molecular mechanisms involved in the early steps of the normobaric hypoxia. Even if hypoxia is a potent modulator of gene expression influencing the expression of approximately 1.0% of the genes in the genome , the identification of a specific oxygen sensor remains elusive. Studies are in progress to evaluate late events responsible for PB-EPCs homing to hypoxic tissues.
- Asahara T, Masuda H, Takahashi T, Kalka C, Pastore C, Silver M, Kearne M, Magner M, Isner JM: Bone marrow origin of endothelial progenitor cells responsible for postnatal vasculogenesis in physiological and pathological neovascularization. Circ Res 1999, 85:221–228.View ArticlePubMedGoogle Scholar
- Iwami Y, Masuda H, Asahara T: Endothelial progenitor cells: past, state of the art, and future. J Cell Mol Med 2004, 8:488–497.View ArticlePubMedGoogle Scholar
- Hristov M, Erl W, Weber PC: Endothelial progenitor cells: mobilization, differentiation, and homing. Arterioscler Thromb Vasc Biol 2003, 23:1185–1189.View ArticlePubMedGoogle Scholar
- Ciulla MM, Lazzari L, Pacchiana R, Esposito A, Bosari S, Ferrero S, Gianelli U, Paliotti R, Busca G, Giorgetti A, Magrini F, Rebulla P: Homing of peripherally injected bone marrow cells in rat after experimental myocardial injury. Haematologica 2003, 88:614–621.PubMedGoogle Scholar
- Crosby JR, Kaminski WE, Schatteman G, Martin PJ, Raines EW, Seifert RA, Bowen-Pope DF: Endothelial cells of hematopoietic origin make a significant contribution to adult blood vessel formation. Circ Res 2000, 87:728–730.View ArticlePubMedGoogle Scholar
- Shintani S, Murohara T, Ikeda H, Ueno T, Honma T, Katoh A, Sasaki K, Shimada T, Oike Y, Imaizumi T: Mobilization of endothelial progenitor cells in patients with acute myocardial infarction. Circulation 2001, 103:2776–2779.View ArticlePubMedGoogle Scholar
- Vasa M, Fichtlscherer S, Aicher A, Adler K, Urbich C, Martin H, Zeiher AM, Dimmeler S: Number and migratory activity of circulating endothelial progenitor cells inversely correlate with risk factors for coronary artery disease. Circ Res 2001, 89:E1-E7.View ArticlePubMedGoogle Scholar
- Gill M, Dias S, Hattori K, Rivera ML, Hicklin D, Witte L, Girardi L, Yurt R, Himel H, Rafii S: Vascular trauma induces rapid but transient mobilization of VEGFR2(+)AC133(+) cells. Circ Res 2001, 88:167–174.View ArticlePubMedGoogle Scholar
- Hristov M, Erl W, Weber PC: Endothelial progenitor cells: isolation and characterization. Trends Cardiovasc Med 2003, 13:201–206.View ArticlePubMedGoogle Scholar
- Takahashi T, Kalka C, Masuda H, Chen D, Silver M, Kearney M, Magner M, Isner JM, Asahara T: Ischemia- and cytokine-induced mobilization of bone marrow-derived endothelial progenitor cells for neovascularization. Nat Med 1999, 5:434–438.View ArticlePubMedGoogle Scholar
- Wang Y, Ahmad N, Wani MA, Ashraf M: Hepatocyte growth factor prevents ventricular remodelling and dysfunction in mice via Akt pathway and angiogenesis. J Mol Cell Cardiol 2004, 37:1041–1052.View ArticlePubMedGoogle Scholar
- Ding S, Merkulova-Rainon T, Han ZC, Tobelem G: HGF receptor up-regulation contributes to the angiogenic phenotype of human endothelial cells and promotes angiogenesis in vitro. Blood 2003, 101:4816–4822.View ArticlePubMedGoogle Scholar
- Abounader R, Laterra J: Scatter factor/hepatocyte growth factor in brain tumor growth and angiogenesis. Neuro-oncology 2005, 7:436–451.View ArticlePubMedPubMed CentralGoogle Scholar
- Ceradini D, Gurtner GC: Homing to hypoxia: HIF-1 as a mediator of progenitor cell recruitment to injuried tissues. Trends Cardiovasc Med 2005, 15:57–63.View ArticlePubMedGoogle Scholar
- Semenza GL: HIF-1 and human disease: one highly involved factor. Gene Dev 2000, 14:1983–1991.PubMedGoogle Scholar
- Semenza GL: Regulation of mammalian O2 homeostasis by hypoxia-inducible factor 1. Annu Rev Cell Dev Biol 1999, 15:551–578.View ArticlePubMedGoogle Scholar
- Minet E, Michel G, Mottet D, Raes M, Michiels C: Transduction pathways involved in hypoxia-inducible factor-1 phosphorylation and activation. Free Radic Biol Med 2001, 31:847–855.View ArticlePubMedGoogle Scholar
- Matteucci E, Locati M, Desiderio MA: Hepatocyte growth factor enhances CXCR4 expression favoring breast cancer cell invasiveness. Exp Cell Res 2005, 310:176–185.View ArticlePubMedGoogle Scholar
- Maroni P, Bendinelli P, Matteucci E, Desiderio MA: HGF induces CXCR4 and CXCL12-mediated tumor invasion through Ets1 and NF- k B. Carcinogenesis 2006. DOI:10. 93/carcin/bgl129Google Scholar
- Laufs U, Werner N, Link A, Endres M, Wassmann S, Jurgens K, Miche E, Bohm M, Nickenig G: Physical training increases endothelial progenitor cells, inhibits neointima formation, and enhances angiogenesis. Circulation 2004, 109:220–226.View ArticlePubMedGoogle Scholar
- Akita T, Murohara T, Ikeda H, Sasaki K, Shimada T, Egami K, Imaizumi T: Hypoxic preconditioning augments efficacy of human endothelial progenitor cells for therapeutic neovascularization. Lab Invest 2003, 83:65–73.View ArticlePubMedGoogle Scholar
- Ciulla MM, Giorgetti A, Lazzari L, Cortiana M, Silvestris I, Annoni G, De Asmundis C, Fiore AV, Montelatici E, Paliotti R, Magrini F, Rebulla P, Cortelezzi A: High-altitude trekking in the Himalayas increases the activity of circulating endothelial cells. Am J Hematol 2005, 79:76–78.View ArticlePubMedGoogle Scholar
- Le QT, Denko NC, Giaccia AJ: Hypoxic gene expression and metastasis. Cancer Metastasis Rev 2004, 23:293–310.View ArticlePubMedGoogle Scholar
- Ciulla MM, Giorgetti A, Silvestris I, Cortiana M, Montelatici E, Paliotti R, Annoni GA, Fiore AV, Giordano R, De Marco F, Magrini F, Rebulla P, Cortelezzi A, Lazzari L: Endothelial Colony Forming Capacity is Related to C-Reactive Protein Levels in Healthy Subjects. Curr Neurovasc Res 2006, 3:99–106.View ArticlePubMedGoogle Scholar
- Ge RL, Witkowski S, Zhang Y, Alfrey C, Sivieri M, Karlsen T, Resaland GK, Harber M, Stray-Gundersen J, Levine BD: Determinants of erythropoietin release in response to short-term hypobaric hypoxia. J Appl Physiol 2002, 92:2361–2367.View ArticlePubMedGoogle Scholar
- Pohlman TH, Harlan JM: Adaptive Responses of the Endothelium to Stress. Journal of Surgical Research 2000, 89:85–119.View ArticlePubMedGoogle Scholar
- Faller DV: Endothelial cell responses to hypoxic stress. Clin Exp Pharmacol Physiol 1999, 26:74–84.View ArticlePubMedGoogle Scholar
- Gampel A, Moss L, Jones MC, Brunton V, Norman JC, Mellor H: VEGF regulates the mobilisation of VEGFR-2/KDR from an intracellular endothelial storage compartment. Blood 2006, 108:2624–31.View ArticlePubMedGoogle Scholar
- Bunn HF: New agents that stimulate erythropoiesis. Blood 2006. DOI 10.1182/blood-2006–08–019083
- Schioppa T, Uranchimeg B, Saccani A, Biswas SK, Doni A, Rapisarda A, Bernasconi S, Saccani S, Nebuloni M, Vago L, Mantovani A, Melillo G, Sica A: Regulation of chemokine receptor CXCR4 by hypoxia. J Exp Med 2003, 198:1391–1402.View ArticlePubMedPubMed CentralGoogle Scholar
- Birchmeier C, Birchmeier W, Gherardi E, Ad Vande Woude GF: Met, metastasis, motility and more. Neture Rev 2003, 4:915–925.View ArticleGoogle Scholar
- Tacchini L, De Ponti C, Matteucci E, Follis R, Desiderio MA: Hepatocyte growth factor-activated NF-kappaB regulates HIF-1 activity and ODC expression, implicated in survival, differently in different carcinoma cell lines. Carcinogenesis 2004,25(11):2089–2100.View ArticlePubMedGoogle Scholar
- Guyenet PG: Neural structures that mediate sympathoexcitation during hypoxia. Respir Physiol 2000, 121:147–62.View ArticlePubMedGoogle Scholar
- Sarkar S, Banerjee PK, Selvamurthy W: High altitude hypoxia: an intricate interplay of oxygen responsive macroevents and micromolecules. Mol Cell Biochem 2003, 253:287–305.View ArticlePubMedGoogle Scholar
- Halliwill JR, Morgan BJ, Charkoudian N: Peripheral chemoreflex and baroreflex interactions in cardiovascular regulation in humans. J Physiol 2003, 552:295–302.View ArticlePubMedPubMed CentralGoogle Scholar
- Papandreou I, Powell A, Lim AL, Denko N: Cellular reaction to hypoxia: sensing and responding to an adverse environment. Mutat Res 2005, 569:87–100.View ArticlePubMedGoogle Scholar
- Grant S, MacLeod N, Kay JW, Watt M, Patel S, Paterson A, Peacock A: Sea level and acute responses to hypoxia: do they predict physiological responses and acute mountain sickness at altitude? Br J Sports Med 2002, 36:141–146.View ArticlePubMedPubMed CentralGoogle Scholar
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